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Türk Anest Rean Der Dergisi 2012; 40(1):52-57
doi:10.5222/JTAICS.2012.052
Epidural Anesthesia for a Parturient with Superior Vena
Cava Syndrome
Serhan Yurtlu, Sedat Hakimoğlu, Volkan Hancı, Hilal Ayoğlu, Gülay Erdoğan, Işıl Özkoçak
Zonguldak Karaelmas Üniversitesi Tıp Fakültesi Anesteziyoloji ve Reanimasyon Anabilim Dalı
SUMMARY
Superior vena cava syndrome (SVCS) is an anesthetic challenge because of its symptomatic cardiovascular, respiratory and neurologic pathophysiology. Decreased venous return to the heart, potential negative outcome of positive
pressure ventilation in the presence of an intrathoracic mass complicate the anesthetic management. If this syndrome
develops during pregnancy, this condition becomes more dreadful because of already existing pressure on inferior
vena cava by gravid uterus. In this case report, we aimed to present anesthetic management of a parturient with SVCS
and endobronchial tumour.
Key words: Superior vena cava syndrome, cesarean, epidural anesthesia
ÖZET
Süperior Vena Kava Sendromu Olan Gebede Epidural Anestezi
Süperior vena kava sendromu (SVKS) semptomatik kardiyovasküler, solunumsal ve nörolojik patofizyolojisinden
dolayı anestezi açısından karmaşık bir durumdur. İntratorasik kitlenin varlığında kalbe azalmış venöz dönüş, pozitif
basınçlı ventilasyonun olası negatif etkileri ile birlikte durumu daha da karmaşık hale getirir. Eğer sendrom hamilelik
sırasında görülürse inferior vena kava üzerinde de mevcut olan uterus basıncının etkisiyle durum daha da kötüleşir. Bu
olgu sunumunda SVKS ve endobronşiyal tümörü olan bir gebede anestezi yönetimimizi sunmayı amaçladık.
Anahtar kelimeler: Süperior vena kava sendromu, sezaryen, epidural anestezi
J Turk Anaesth Int Care 2012; 40(1):52-57
Alındığı Tarih: 23.12.2010
Kabul Tarihi: 09.03.2011
Yazışma adresi: Doç. Dr. Volkan Hancı, Çanakkale Onsekiz Mart Üniversitesi Tıp Fakültesi Anesteziyoloji ve Reanimasyon
Anabilim Dalı, ÇOMU Uygulama Araştırma Hastanesi, Merkez Ameliyathaneleri, Kepez, Çanakkale
e-posta: vhanci@gmail.com
52
S. Yurtlu ve ark., Epidural Anesthesia for a Parturient with Superior Vena Cava Syndrome
INTRODUCTION
CASE
Superior vena cava syndrome (SVCS) is a
common complication of malignancy, especially of lung cancer and lymphoma.(1)
Patients may present with several symptoms which in decreasing order of frequency include facial and neck swelling,
arm swelling, dyspnea, cough, and dilated chest veins.(1)
The patient was a 32 y/o G2, P1 parturient at 31. gestational week who presented at our obstetrics and gynecology service for progressively increasing dyspnea.
Her cough and dyspnea had begun one
month before and she had been given
symptomatic treatment previously at an
another hospital. Initially, pneumonia
was suspected, antibiotic therapy was
initiated combined with a mucolytic, and
tests were performed to rule out tuberculosis. Despite treatment, the dyspnea was
not relieved, and clinically evident SVCS
presented on the 6th day of her hospitalization. She had bilaterally dilated veins
on the neck, upper part of chest wall and
arm sweling especially on the right. Chest
radiograph has shown total atelectasia
of the right lung, mediastinal enlargement and deviation of trachea to the left
(Figure 1). Thoracic and abdominal magnetic resonance imaging revealed a large
anterior mediastinal (85x60 mm), and a
relatively smaller endobronchial mass (40
mm) occluding the right main stem bronchus, and lesions within the parenchyma
Worrisome signs include stridor, as an indicative of laryngeal edema, and as confusion, obtundation which might indicate
cerebral edema. An ominous sign in our
patient was stridor, suggesting tracheal
compression by an anterior mediastinal
mass. Presence of respiratory and neurologic compromise can be associated with
serious or fatal outcomes in SVCS.(1)
If SVCS occurs during pregnancy, the symptoms are worsened by the physiologic
changes of pregnancy, especially pressure
on the inferior vena cava by the gravid
uterus, which has an additive effect on the
impaired venous return because of compression of the superior vena cava.(2,3) Due
to rarity of the condition, there are only
a few cases in the literature reporting anesthetic approach to the parturients with
SVCS.(2,3) Optimal anesthetic management
for the parturient with SVCS remains to
be determined.(2)
In this case report, we present our anesthetic approach to a parturient in whom
SVCS coexist with total obstruction of
right main stem bronchi, a highly life
threatening condition, managed with
epidural anesthesia.
Written informed consent has been obtained from the patient for publication.
Figure 1. Antero-posterior chest radiograph
showing large mediastinal tumor deviating
the thrachea and complete atelectasia of the
right lung.
53
Türk Anest Rean Der Dergisi 2012; 40(1):52-57
Figure 2. Thoracic magnetic resonance imaging showing near complete obstruction of
superior vena cava.
of the left lung and liver (Figure 2). Our
obstetric team decided that cesarean section was indicated to preserve the life of
the mother. Fetus was 32 weeks old at the
time of scheduled cesarean delivery
The results of the preoperative arterial
blood analysis of the patient under ambient conditions were as follows; pH: 7,48,
pO2: 69 mmHg, pCO2: 29 mmHg, HCO3: 21
mEq/L. Transthoracic echocardiography
demonstrated a minimal pericardial effusion, ejection fraction of 60 %, and no evidence of intracardiac tumour or thrombosis. Because of the potential morbidity
associated with positive pressure ventilation in the presence of a symptomatic anterior mediastinal mass, regional anesthesia was chosen.
Upon arrival into the operating room two
intravenous cannulas were inserted, one
to the left arm, the other to the right leg
from dorsal aspect of the foot. Infusion of
lactated Ringer’s solution was started at
approximately 15 mL kg-1 hr-1. Radial arterial cannulation was performed on the
left arm, revealing arterial blood pressure
54
of 130/80 mmHg. The patient was placed
in the left lateral position to avoid further
aortocaval compression. The epidural
space was identified at the L3-4 level using
loss of resistance technique by saline
injection. Catheter was easily inserted
into epidural space and fixed to skin with
an epidural clamp (SIMS Portex®, Hythe,
UK). Negative aspiration is confirmed and
a test dose of 3 mL of 2 % lidocaine containing 200.000-1 epinephrine was given.
Since a sensory block at T4 level was reported to be obtained with 15 mL of local
anesthetic-opioid mixture in a similar patient(2), we injected 12 mL of additional local anesthetic-fentanyl mixture (20 mL 0.5
% levobupivacaine plus 100 µg fentanyl)
with a slow, incremental injection technique.(2,4) At the 10th minute of injection,
bilateral sensory block at T10 level was obtained. In order to achieve sensory block
at T4 level, 5 mL of local anesthetic-opioid
mixture was injected 2 times, and finally
5 mL 0.5 % levobupivacaine administered
through the epidural catheter. Injection
of local anesthetics was completed in 30
minutes. Upper level of sensory block was
T8 at the end of 35 minutes, and it didn’t
rise any further during the monitorization. Fetal heart rate remained within
normal limits during this period. Maternal hemodynamics was essentially stable
with no need for sympatomimetic drug
or atropine. Surgery was uneventful until peritoneal closure, and the patient was
totally pain free. Neonate’s Apgar score at
1st and 5th minute were 9 and 10 points,
respectively, fetal blood pH obtained from
umblical cord was 7.37. When peritoneal
closure was performed, we administered
supplementory intravenous fentanyl (100
µg in two divided doses) and propofol
(50 mg, in total, multiple administrations)
because the patient felt pain at her right
upper shoulder. Spontaneous ventilation
S. Yurtlu ve ark., Epidural Anesthesia for a Parturient with Superior Vena Cava Syndrome
was maintained at all times. There were
no intervals of apnea or need for positive
pressure ventilation. Just after the end
of surgery, diagnostic bronchoscopy with
topical anesthesia utilizing lidocaine is
performed at the operation theatre, and
a endobronchial tumour totally obstructing right main bronchi at carinal level was
seen. During bronchoscopy biopsy material was taken by pulmonologists for histopathological diagnosis.
Since the diagnosis was an endobronchial
tumour, our obstetric team decided to
start anticoagulant prophylaxis consisting of 0.4 mL enoxaparin administered
subcutaneously. Therefore, we decided
to administer a single dose of 3 mg epidural morphine and remove the catheter
for safety of the anticoagulant therapy.
Epidural morphine was given at the second postoperative hour, and the catheter
was removed. Anticoagulant therapy was
initiated for 2 hours after the catheter removal.(5)
After an uneventful first postpartum day,
the patient was transferred to the Pulmonary Service, anti-edema therapy was initiated and the patient was prepared for
radiation therapy for palliation of SVCS.
Shortly after, symptoms were greatly improved. Diagnostic testing revealed that
SVCS was a consequence of an aggressive
malignant mesenchymal tumor of the
lung. Unfortunately, the patient died one
month after the delivery.
DISCUSSION
Intrathoracic tumour does not always
lead to SVCS but it is a common complication of malignancy. Malignancies in pregnancy occur in 1.000-1 of all pregnancies,
and parturients with intrathoracic tumors
are less frequently encountered.(2) There
have been less than 50 cases of lung cancer in pregnancy reported to date.(6) Intrathoracic tumor results in SVCS in 2-4 %
of the patients at some point during the
course of the disease. This makes the circumstances of our patient truly unusual,
and the anesthetic management issues
challenging.
Previous reports indicate that general
anesthesia is associated with significant
morbidity and mortality rates in patients
with SVCS.(7-10) Anterior mediastinal mass
combined with obstruction of superior
vena cava can present a challenge for
general anesthesia because of severe
hemodynamic compromise secondary to
compression of the heart and great vessels. Positive pressure ventilation will
exacerbate hemodynamic instability by
increasing intrathoracic pressure, rapidly
decreasing venous return, and potentially
compromising an already narrowed airway related to the physiologic changes
of pregnancy.(2,11) Intraoperative mortality
secondary to cardiac compression without
any evidence of tracheal obstruction mediastinal masses has been reported.(2,8,12)
General anesthesia should be avoided,
because of the risk of difficult mask ventilation, difficult intubation, airway edema,
and paralysis of the vocal cords postoperatively.(2,8)
Two reported cases demonstrated use of
epidural anesthesia in parturients with
SVCS, resulting in good outcomes.(2,3)
Their favourable outcomes suggest epidural anesthesia as a method to ensure a
good outcome. In both of these reports
only 15 mL of local anesthetic was necessary for obtaining T4 level of sensory
blockade. Use of epidural anesthesia has
been reported for cesarean section in a
55
Türk Anest Rean Der Dergisi 2012; 40(1):52-57
parturient with tracheal tumor.(13) On the
other hand, spinal and continuous spinal
anesthesia were used for parturients with
intrathoracic masses without symptoms
of SVCS.(14,15) The authors described successfully managed anesthetic course with
both regimens. Patients and babies had
done well with this techniques in those
case reports.(13-15)
Spinal and continuous spinal anesthesia have been used in parturients with
intrathoracic masses without SVCS with
good outcomes.(13-15) We did not select
spinal anesthesia for our patient because
sudden sympathectomy could have created serious hemodynamic compromise.
Combined spinal-epidural technique
wasn’t preferred since the incidence of
hypotension is similar to spinal anesthesia.(16) We considered continuous spinal
anesthesia to allow a slower onset, but we
were unsure about the distribution of local anesthetics in the subarachnoid space
related to SVCS.(3) We selected an epidural
anesthetic to allow incremental injection
and slow onset of pharmacological sympathectomy. The outcome of the epidural
block was a surprise, with the sensory level never exceeding T8, despite a large volume of local anesthetic. We think that it
could be the result of increased epidural
pressure in our patient. Similarly, Kawamata et al.(17) shown an increase in baseline cervical epidural pressure up to 36
mmHg in a patient with SVCS syndrome.
They had stated that after the development of SVCS, cervical epidural pressure
had risen to 98 mmHg after injection of
6 mL local anesthetic, and epidural fluid
flow changed its course to the caudal direction. This could explain the inability to
move the sensory level above T8 in our patient.(17)
56
The low level achieved in this case despite
large volume of local anesthetic suggests
that high epidural pressure should be suspected in parturients with SVCS.
Previous case reports had shown that, severe hemodynamic compromise secondary to compression of the heart and great
vessels may occur in general anesthesia
application for SCVS.(2,8,11,12) In our case
report, hemodynamic parameters were
almost unchanged during the induction
and maintanence of epidural anesthesia. However hemodynamic parameters
should be carefully monitorized in such
patients.
We conclude that, from the hemodynamic point of view, epidural anesthesia was
well tolerated by our patient with SVCS,
but its limitations about the upper level
of sensorial block should be taken into
consideration.
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